On 20th May 2019 Hugh McCaughey (@HughMcCaughey), National Improvement Director for the NHS in England led his first #Improve4Patients tweet chat. It was hosted by the NHS Horizons team (@HorizonsNHS) who also prepared this report. The tweetchat lasted for one hour from 7pm to 8pm.

These were the questions asked during the tweet chat:

What happened during the tweet chat?

777 people joined the chat (data from Followthehashtag). The tweet chat was promoted and supported by a group of 31 "Improvement superconnectors"; people active in the improvement movement in the English NHS who have broad networks of influence on social media. Their efforts attracted a large, diverse group of contributors to the tweet chat.

These are the tweet chat influencers as identified by the Symplur analytic platform:

The graph below from NodeXL evidences how diverse groups of people were connected by the tweet chat. The clusters are individuals and accounts that tweet about similar issues, and the green lines show that they were connecting with one another during the tweet chat, building a strong improvement community (click here to see a larger version). Thank you to Dr Graham Mackenzie, a Scottish trainee GP, who created this graph.

We are delighted to see that people are continuing to build this community beyond the tweet chat by using the #Improve4Patients tag.

The NHS Horizons team evaluated the 1,991 tweets sent during the tweet chat (data from Symplur) and identified 49 specific ideas.

We grouped the feedback and ideas in to the following themes:

Specific improvement ideas

Joined-up working

Shared purpose

Creating conditions for improvement

Co-production with patients

Capacity for improvement

Training

Measurement for improvement

Language

Regulation

(Tip: To view an original tweet click on the image, click on the red text to view response tweets)

We have pulled out key tweets under each of these headings below. You can also read more of the tweets in our Twitter Moment.

Specific improvement ideas

Rebecca Barrett told us about the staff nurse led project working across facilities and professions to give patients a more tailored service.

Rebecca Barrett also described the work at Nottingham to improve the patient offer for smoking cessation. They now have specific leaflets and double figures of nurses trained in very brief advice.

Rachel Crooks' team has been working on improving blood monitoring & appropriate follow up for patients on systemic/biologic drugs; valuing patients' time and only bringing them to hospital when essential.

Tanya Saker shared this pressure point injury graphic from North Bristol Trust.

The @SignUpToSafetycampaign was effective, said Mark Juniper: it provided focus & structure to enable local QI work.

Brian Dolan shared 'The impact of involving nurses in quality improvement: an international review' that Jane Robinson wrote for her doctoral work.

Joined-up working

In Nottingham, they join teams up together working across an integrated care system (ICS) as Steve Daykin explained.

Suzie Bailey agreed, saying that we should help to stop reinventing approaches and evolve them instead.

Yvonne Hastings reflected that we ought to provide more platforms with similar teams across regions, to network and learn from each other.

Charlotte Fox suggested using existing infrastructure and networks that are well-established and have the ability to cultivate, capture, and disseminate good work.

Success for Paula Shore has come from working locally, regionally and nationally understanding issues from the acute up to national level and sharing learning from this.

Vin Diwakar said NHS Strategic Clinical Networks convene, champion, call out variation, challenge constructively, commission & change culture across systems & enable large scale change.We need to invest in creating a common community and shared approach to quality improvement across public services respectful of our different contexts and local languages said William Lilley.

Caroline Poole is leading a quality orthotics programme with some 20 trusts across the country - collaborating to measurably improve experience and outcomes, build Allied Health Professional Leadership and #QI capability and capacity. Tim Gillatt explained that they are encouraging operational teams to visit each other through our safer collaborative. Tim said they've loved the opportunity to see what other people are doing in other hospitals and pinch with pride.

There is a power in connection and learning across a network, reflected Amar Shah.

Ceri Charles agreed, saying these networking sessions often give you the precious time and space to step out of your role and connect with others

At Gloucestershire Safety & Quality Improvement Academy they ask staff to register their projects. Where there are similar projects they aim to connect teams so they are not duplicating effort. Plan-Do-Study-Act (PDSAs) are also very important so only changes that work are implemented & spread. They do this via a Google forum. Louise also said all staff doing QI through the Academy are allocated a QI facilitator for duration of their project. Collaboratives offer additional opportunity to work with wider teams. Louise echoed Helen Bevan's observation that magic happens when local teams at the point of care redesign their own services.

Sue Holden thought it would be a good idea if each organisation had a register of staff who trained and applied their improvement approach.

Jonathon Gray suggested that we should join up all Q, IHI, Health foundation and all thousands of staff; don't create new departments.

It is a national role to prepare conditions / set out principles of improvement and leadership development to ensure compatibility, said Tom Downes.

Lesley Goodburn is working in NHS England & NHS Improvement to bring together patient experience and QI in a more interdependent integrated way.Creating conditions for improvement

Helen Bevan said the national/nationwide role in improvement is changing fundamentally. The role used to be running national improvement programmes. Increasingly, the role is about creating spaces (face to face & virtual) where local improvement leaders can learn & share.

Seema Srivastava works with teams to support them with QI work so that they use the training to deliver improvements for patients. They have a QI hub every week where teams drop in and provide coaching and junior doctor training.

Vardeep responded to say that this shows the value of relationship building when on you are journey of improvement.

Carolyn Johnston said her best work has been possible when the team had ring fenced time outside clinical work, and good metrics to work from.

Lynne Bowers shared her belief that staff and people need protected time and space, permission to attend, not being 'bleeped' out to attend to 'urgent' matters.

Leeanne Lockley had a similar reflection: to give people time to understand what’s expected of them; let them ask questions and answer them open and honestly - QI is a marathon not a sprint!

Minesh Khashu thought a big objective should be to teach NHS boards to understand QI better. It is a weak link at present and pushes organisations to a reactionary behaviour rather than continuous improvement.

Improvement needs to be linked back to strategic objectives and overall organisational aims - consistency, always with the patient in mind reflected Lou Waters.

The senior leadership team and Board at Warrington and Halton Hospitals seeing it as a top priority and support the development of their Quality Academy, said Ursula Martin.

Vin Diwakar said that his projects have worked because of an acceptance by senior leaders that large scale change is messy and just because it doesn't follow a linear approach doesn't mean it isn't good.

This was echoed by Rachel Crooks, who said that continuous feedback is important in the success of a project. Mentoring is crucial said Abi Byrchmore, who asked for more support when starting and finding your way through your first project.

Darshan Patel wondered whether an organisation needs to slow down and consolidate efforts periodically after reflection of where an organisation is, and what will lead to long term sustainability and impact?William Lilley said we have to spend more time understanding how to foster the local leadership behaviours that create that rarest of qualities 'psychological safety' #improve4patients that seems to make or break improvement efforts.

This was echoed by Hassan Al-Omari, who thinks its important to understand that its ok to fail so long as the lessons learned are applied to the future. We need a culture of safe exploration of QI projects.

Richard Best suggested having a little space with a team to examine purpose, allowing them to own what they want to change, guiding them with simple steps - celebrate learning success or not.

Emma Saunders had a similar reflection: she has found that listening to front line staff and giving them permission to make the changes that are needed has been a great start. Emma says we need more of this, more transparency, more two way communication and more opportunity to put heads together and develop ideas nationally. Emma is passionate about empowering her colleagues to find their “agency” and making real and meaningful change happen at a grassroots level as she described in this tweet.

Hugh McCaughey said we should be seeking to empower the hundreds of thousands of front line staff who want to make their services better.

The East England Ambulance Service explained that it's important to encourage improvement ideas from all grades and levels of staff from your office admin through the chief exec! A lot of answers/suggestions come from their crew rooms. Similarly Steve Daykin agreed with this; he said the project leads does not have to be and should not always be the team leaders and service managers. They can be and should be frontline staff being nearest the change ideas.

Hugh McCaughey said his former organisation South East Trustalso trained staff at every level. He recently walked on to a ward where every staff member working at band 3 was undertaking an improvement project.

Charlotte Fox reinforced the importance of decision makers listening to the front line. Rebecca Barrett says this not happening is a reason she feels unable to change things.

Rebecca Barrett suggested shared governance empowers nurses to attempt to change things for the better. There are hundreds of staff actively looking to make improvements for patients. Supported centrally, given training, opportunities to write up and share practice wider.

Compassionate culture is essential, said Sally Brown. Staff need to feel restored and supported to improve - they cannot change/improve from an empty cup. Stressed and burned out staff have no head space for improvement or compassionate care. Invest in well being, tackling stress and burnout.

Great wisdom from Caroline Poole, who summed up much of the sentiment in the tweet chat: Coaching not telling. Learning not failing. Measuring not guessing. Team not solo. Appreciating strengths not searching for failings. Celebrating success. Being visible. Shared power. Oh, and as much fun, laughter, joy as possible.

Jane Douthwaite felt it is important we move beyond consultation and co production with improvements and let users and staff at the point of care co design solutions, test, implement & evaluate.

Steve McCue agreed it's all about relationships, and "integration moves at the speed of trust".

This sentiment was echoed by Sue Holden, who reminded us that we need to remember improvement happens with through and by people; by Sarah Cooper, who reflected that collaboration, conversations, relationships, and thinking of how this will impact care for our citizens is needed; and by Sameena, who said "When there is trust, then people seem to go with the fails and the wins. When things go wrong and people can still look at the positive lessons - that feels great!" Sound data, strong relationships with teams, collaborative working, interdisciplinary work, celebrating success was a contribution from The Centre from Sustainable Healthcare. Tom Downes had a similar description of what has been important to his improvement work.

Lou Waters summed it up, saying it's important to engage people from the beginning to co design solutions. Not doing change TO people, but bringing them with you.

Lynne Winstanley reflected: true and real involvement with all key players within any improvement journey, creation of a shared purpose and skills of all involved.

Co-production with patients

We must ask the patients and staff on frontline what matters to them. If they own the issue they will come up with the solution using QI methods said Farzana Hussain.

This view was supported by Claire Shields who said patient choice is key in encouraging improvement; Lynnette Lee who expressed the importance of asking people who will be affected or benefit from change; by Steve McCue, who reflected that we must consider the wider determinants of health and how we collaborate better with patients; and by Sally Brown, who said involving people (patients, families carers) is absolutely essential.

In response Bill Russell explained that all patients are different, and it would be helpful to hear these opinions on what needs to be improved. Bill also said patient participation all too often is a tick box exercise tacked on to the end, often as a consultation that is ignored with no feedback.

Nicola had a similar reflection: she said too much is driven by those with no lived experience/direct knowledge.

Lynne Winstanley asked the important question: How do we strengthen involvement in #QI from the real people who use our services how do we really co-design with our true customers?

Elaine Latham said in the South West patients and public trained in QI meet with improvers as part of a panel discussion.

Paul Conroy echoed this sentiment: "It's time to see patients & carers as part of the team delivering and improving care".

Matthew Mezey suggested we encourage the spread of coproduced 'Always Events' around the UK - to guarantee patients can always give positive reports when they've received excellent care.

There is good practice with co-production, as Jennifer Poll described:

London Clinical Networks has a big drive to recruit patients and carers to inform the work done in Hassan Al-Omari's team.

James Mountford has found that putting more emphasis on coproduction is a great way to highlight unnecessary cost, waste and complexity as well as staff frustrations.Co-design has helped PReCePT communicate effectively with their users.

Shared purpose

Jane suggested the next initiative that is put out talks about the WHY first and not the HOW and WHAT? Shared purpose = sustainable effective change.

Alice O'Neil agreed: the shared purpose is the 'reason why', the driver and connection across all. Lynnette Lee also explained the importance of shared purpose.

Steve Daykin reflected that to succeed with an initiative we must keep things simple, the training we deliver is not mandatory and staff contact us to get on the training, a dynamic and enthusiastic QI team build from within the existing clinical staffing with an autonomous approach.

Seeing seeing sustainable improvements for patients while empowering staff to make supported changes and where things don't go well, share it are important elements for Chris Richmond.

Elaine Latham said involvement can be at any level as long as it’s meaningful and valued.The lean management system at Medway ensures they have a consistent message to align their staff behind as a ‘line of sight’ to establish a strong support across the trust said Nick Chambers. They have trained more than 100 staff in yellow belt, and 200 in white belt.

Capacity for improvement

We need a system level idea of capability and capacity to affect change at scale and pace, said Minesh Khashu.

William Lilley is working with Billions Institute to develop the capacity and capabilities of #NHS leaders to be confident at leading large scale spread and adaption of innovations across their communities and local systems.Andrew Seaton said we need to learn how to speed up the journey to develop capability and capacity for QI without losing the organisation learning you get from going on the journey.

Amanda reflected that at a national and regional level there should be an understanding of and support for the longer-term, incremental approach to improvement rather than a focus on immediate turnaround of difficult problems.

Training

Amar Shah said at East London Foundation Trust service users & carers have been part of all of their training for years. People to be supported to be meaningfully involved in improvement.

In Gloucestershire, they are launching a new quality framework building governance to support #QI across divisions, training improvement coaches who will coordinate #QI programs in their specialties starting with the question 'what matters to us /our patients'.

Charlotte Fox has been working with local universities around the implementation science that needs factoring into any improvement.

Sarah Cooper asked whether there is something about undergrad training this is where the QI journey starts for most but are the links made and embedded so it becomes business as usual and not the role of specific individuals?

Carolyn Johnston is producing a QI guide for specific projects in anaesthesia, matching the curriculum and college clinical guidelines to suggested QI activities.

Measurement for improvement

Chris Green is helping systems across the NHS understand, and use, meaningful information and provide analysis / modelling tools to support improvement.

SusHealthcare supports teams to evaluate their projects using the 'triple bottom line' of environmental, social and financial costs (or added value). This creates a richer sense of the value of healthcare and includes environmental aspects.

Language

We need to acknowledge at all levels that not all improvement is technical or quantitative, reflected Rachel Crooks.

Caroline suggested using plain English rather than technical words to be more inclusive.

A suggestion from James Mountford to call it improvement rather than QI.

Pete Gordon shared this Einstein quote.

In response Rosanna Hunt asked, do different audiences require different messages, in your experience - or does one simple headliner, or "elevator pitch" do the job well enough?

Regulation

Sasha Karakusevic said nationally we need to create the environment for individuals, organisations and systems to prosper. That’s about framing, coaching, sharing and fostering.

Pete Gordon said there needs to be a more balanced approach between improvement and regulation. It’s too one sided at the present time.Amanda agreed, stating,the hardest part is defining what the ideal will look like and then how to meaningfully measure that easily and in a way that is visually simple so everyone can see and review .

Richard Best shared that we need a serious think about blending 'branded' approaches and get back to building capability of teams to be inspired and capable of measured change. We need to start understanding why regulation has not always inspired building of capability for improvement.

Amar Shah said he can think of few things that excite teams more than the opportunity to improve the system they work in, for and with those they serve... but it has to be authentic, and with genuine support available